Written by Peter Liu
Spoon Feed
Left atrial appendage occlusion (LAAO) done at the same time as atrial fibrillation (AF) ablation reduces bleeding risk and may become part of standard of care in the future.
Summary
Today, we’re covering two studies in one post.
First, the OPTION trial explored whether left atrial appendage occlusion (LAAO) could reduce bleeding risk compared to anticoagulation in atrial fibrillation (AF) patients post-ablation. This randomized study (n=1600) demonstrated that LAAO was superior in reducing non-procedural bleeding (8.5% vs. 18.1%; P<0.001) and noninferior in preventing death, stroke, or embolism (5.3% vs. 5.8%; P<0.001). Complications included device-related thrombosis in 1.9%. Key limitations were sponsor involvement (WATCHMAN) and lack of inclusion of other LAAO devices.
Next, the COMBINATION trial compared procedural sequences (ablation-first vs. occlusion-first) in LAAO and catheter ablation for AF. The occlusion-first strategy (n=97) resulted in superior event-free survival (83.5% vs. 71.1%; HR 0.53; P=0.04) and lower arrhythmia recurrence. Limitations included small sample size and lack of blinding. (AI-assisted)
Could left atrial appendage occlusion become a standard part of atrial fibrillation ablation?
Conventionally, AF ablation was only thought to help make patients feel better and need less toxic anti-arrhythmic medications (i.e. “rhythm control”). Until recently, the procedure was not thought to improve “hard” cardiovascular or stroke outcomes unrelated to symptoms. For example, it was not thought to meaningfully lower stroke risk, nor modify the need for anticoagulation in patients with high stroke risk. This understanding of AF ablation seems to be rapidly changing, just as the technologies and tools utilized during the procedure itself are changing.
- Results from the OPTION RCT found that AF ablation paired with LAAO allowed patients to stop anticoagulant medications 3 months after the procedure and decreased bleeding risk thereafter, without increasing the risk of death or stroke.
- The COMBINATION RCT found the procedural sequence of LAAO first, followed by AF ablation, resulted in even better post-procedural outcomes, driven predominantly by lower rates of device-related thrombus and peri-device leak.
- For LAAO procedures in the U.S., insurance authorization for the procedure tends to be the rate-limiting step for most patients. Time will tell whether combination LAAO/AF ablation becomes part of standard care.
Sources
OPTION Trial Investigators. Left Atrial Appendage Closure after Ablation for Atrial Fibrillation. N Engl J Med. 2024 Nov 16. doi: 10.1056/NEJMoa2408308. Epub ahead of print. PMID: 39555822.
COMBINATION Trial Investigators. Strategy Optimization for a Combined Procedure in Patients With Atrial Fibrillation: The COMBINATION Randomized Clinical Trial. JAMA Netw Open. 2024 Nov 4;7(11):e2445084. doi: 10.1001/jamanetworkopen.2024.45084. PMID: 39546313
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